Field-Based HIV Care Outreach Navigator

Boston Health Care for the Homeless Program; Boston (MA); On-site; USD 31,000 - 49,000; Full time

Job summary

Boston Health Care for the Homeless Program is seeking an Outreach Case Manager to participate in an innovative multidisciplinary HIV Primary Care Team in greater Boston. You will provide community-based outreach, linkage, and retention services to help patients engage in HIV care and remain connected to services.

Working with Outreach Nurses and a Social Worker, you will address barriers such as housing instability, substance use, and access to benefits, and you will develop Individual Service

Qualifications

• Associate’s or bachelor’s degree in a related field or equivalent to two years’ relevant human services experience.
• Experience and interest in working with people living with HIV and experiencing homelessness.
• Experience conducting outreach in non-clinic-based settings.

Responsibilities

• Accompaniment to medical, social service, housing and legal appointments and debriefing with patients after visits and updating HIV team and collaborating agencies as needed
• Active follow-up on client referrals to a wide range of support services
• Field-based outreach and other activities to locate patients who may be out of care, or at high risk of disengaging from care.
• Co-create Individual Service Plans with clients as well as with input of the multidisciplinary HIV team, monitor implementation of plans and document updates in electronic medical record
• Ensure linkage to emergency psychiatric services, when necessary, in partnership with behavioral health team
• Assist with care coordination during discharge planning for patients in an inpatient setting at local hospitals
• Provide advocacy for patients involved in the criminal legal system, assist patients in reconnecting to care in the post-release period
• Provide motivational interviewing and risk reduction counseling for patients with substance use disorders, as well as for those engaging in other high-risk behaviors
• Work with team to identify potential candidates for linkage and retention intervention; as well as to identify patients who are ready to transition from the intensive outreach to more clinic-based traditional case management services
• Document all client interventions/activities and referrals in electronic medical record
• Complete all reporting duties as required by grant agencies, and other reports as requested
• Fulfill all mandatory reporting duties as required by MA regulating agencies
• Participate in weekly multidisciplinary Patient Care Meetings and monthly HIV Team meetings as well as attend Team Huddles as appropriate
• Successfully complete the MassHealth Certified Application Counselor exam (CAC) within 60 days of hire and maintain active certification status.
• Provide documentation for grants, projects, etc. as directed by the Supervisor
• Participate in intra-agency committees

Skills

Computer proficiency

Organizational skills

Interpersonal skills

Communication skills

Trauma-informed care

Motivational interviewing

Risk reduction

Bilingual English-Spanish

Education

Associate’s or Bachelor’s degree

Job description

Boston Health Care for the Homeless Program is seeking an Outreach Case Manager to participate in an innovative multidisciplinary HIV Primary Care Team in greater Boston. You will provide community-based outreach, linkage, and retention services to help patients engage in HIV care and remain connected to services.

Working with Outreach Nurses and a Social Worker, you will address barriers such as housing instability, substance use, and access to benefits, and you will develop Individual Service